Medicare Advantage (Medicare Part C)

 

Medicare Part C, or Medicare Advantage, is a program that offers an alternative way to receive your Original Medicare benefits (Part A and Part B).

Medicare Advantage plans are available from private insurance companies that contract with Medicare. They’re required to cover everything that Original Medicare (Part A and Part B) does, except for hospice care, which Medicare Part A covers when you have a Medicare Advantage plan. Under the Medicare Part C program, you get your Original Medicare coverage through the Medicare Advantage plan instead of directly through Medicare.

If you sign up for Medicare Advantage, you aren’t leaving the federal Medicare program. You actually remain enrolled in Medicare Part A and Part B. Many Medicare Advantage plans include extra benefits as well, such as wellness programs or routine vision care. Most of them include prescription drug coverage.

In many cases, Medicare Advantage plans (such as Health Maintenance Organizations, or HMOs) include networks of clinics, doctors, and hospitals. If you belong to one of these plans, then you may need to seek treatment from providers within that network, or risk paying considerably more in out-of-pocket spending.

There are several Medicare Advantage plan options, although not every plan type may be available in your area. You may want to compare the available options, as each plan’s coverage details may differ. Consider all your current health-care needs before making a decision, such as whether you need prescription drug coverage. You may also wish to consult your doctor and other health-care providers to see what they recommend in terms of your coverage scope.

What Medicare Advantage plans are available?

Here are some brief descriptions of common types of Medicare Advantage plans. Each of these is available from private insurance companies that contract with Medicare. Availability and cost may vary by plan and service area.

Medicare Preferred Provider Organization (PPO)–A network of doctors, clinics, hospitals, and other health-care providers. With this type of plan, you don’t have to choose a primary care physician up front to coordinate your care. Instead, you can see any doctor or specialist who accepts Medicare assignment. If you go to providers outside your PPO network, your out-of-pocket costs may increase.

Medicare Health Maintenance Organization (HMO)–A type of plan in which you choose a primary care physician who will coordinate your care and refer you to any specialists you have to see. An HMO typically has a network of health-care professionals, and going outside of that network could require you to pay the full amount for any services.

Medicare Private Fee-for-Service (PFFS)–A type of Medicare Advantage plan in which the plan, not Medicare, sets payment terms. Some plans cover your visits to any doctor or specialist without worrying about network restrictions if the doctor or health-care provider accepts the plan’s terms, fees, and conditions. Other PFFS plans have provider networks.

Medicare Special Needs Plans (SNPs)–Plans designed for people with certain chronic diseases or other special health needs. All of these plans must include prescription drug coverage.

Medicare Medical Savings Account (MSA)–Plans consisting of two parts:

  • A high-deductible plan where coverage doesn’t start until the annual deductible is met.
  • A savings account plan where Medicare deposits money to help you pay toward the high-deductible amount.

Do you need prescription drug coverage?

Not all Medicare Advantage plans include prescription medication coverage, but most do. When comparing plans, ask the plan (or review its description) to make sure it includes drug coverage if that coverage is important to you.

Who’s eligible to enroll in a Medicare Advantage plan?

To be eligible for Medicare Part C, you must already be enrolled in Original Medicare, Part A and Part B. You continue paying your Part B premium, along with any premium your Medicare Advantage plan may charge. You must live within the plan’s network, and in most cases you’re not eligible if you have end-stage renal disease (although there are exceptions, and some Special Needs Plans may accept you).

When can you enroll?

To enroll in a Medicare Advantage plan, you can take advantage of certain election and enrollment periods.

The Initial Coverage Election Period (ICEP) is when you’re first eligible for a Medicare Advantage plan.

When you become eligible for Medicare and you’re enrolled in Medicare Part A and Part B, you can enroll in a Medicare Advantage plan. In this case, your ICEP is the seven-month period that starts three months before the month where you turn 65, runs through your birth month, and continues for the three months after that. This is the same as your Medicare Initial Enrollment Period.

If you don’t sign up for Medicare Part B when you’re first eligible (for example, if you’re covered through an employer’s plan), your ICEP is the 3-month period before your Part B start date. For example, if you enrolled in Part B during the General Enrollment Period (January 1 to March 31), your Part B start date would be July 1, so your ICEP would be April 1 to June 30.

Your next chance to enroll in a Medicare Advantage plan is during the Annual Election Period (AEP), also called the Open Enrollment Period for Medicare Advantage and Medicare prescription drug coverage. It runs from October 15 to December 7 each year. You can add, change, or drop Medicare Advantage plans during the AEP, and your new coverage starts on January 1 of the following year.

If you have Original Medicare, you can also add a stand-alone Medicare Part D Prescription Drug Plan during the Annual Election Period. Alternatively, you can leave your Medicare Advantage plan, return to Original Medicare, and add a stand-alone Medicare Prescription Drug plan.

In some situations, you can enroll in a Medicare Advantage plan during a Special Election Period. Examples of these situations include (but are not limited to): moving to a new address, losing your current health coverage, qualifying for a different type of coverage, or experiencing changes in your current plan that affect your health benefits.

If you decide to drop your Medicare Advantage plan and return to Original Medicare, Part A and Part B, you can do so during the Medicare Advantage Disenrollment Period, from January 1 to February 14 each year. You can also add a stand-alone Medicare Part D prescription drug plan during this time.

How do you enroll?

Medicare Advantage isn’t as complicated as it sounds. Before you decide on the type of Medicare insurance plan that may work for you, we recommend that you understand the coverage and costs, such as premiums, coinsurance, copayments, and deductibles. This isn’t guesswork; don’t be afraid to ask questions. A licensed eHealth insurance agent can help you find the answers. For help finding a plan to suit you, feel free to contact eHealth using the information below.

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